Provider Demographics
NPI:1790443398
Name:LAKE, PERRY LEE (LMT/CMT)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:LEE
Last Name:LAKE
Suffix:
Gender:M
Credentials:LMT/CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S DAVID ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-7249
Mailing Address - Country:US
Mailing Address - Phone:208-241-1632
Mailing Address - Fax:
Practice Address - Street 1:1101 S DAVID ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-7249
Practice Address - Country:US
Practice Address - Phone:208-241-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6711070-4701225700000X
IDMAS-3291225700000X
TXMT107775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist